• 2025 Participant Information Sheet

    2025 Participant Information Sheet

    Cancer Support Community Delaware gathers information annually about every participant, both new and returning, to help us better support you. All information provided is always kept confidential and protected. Thank you in advance for taking time to fill out this form annually.

  • Contact Information

  • Emergency Contact Information

  • COVID-19 Vaccination Status

    We recommend that you be fully vaccinated and boosted before entering our offices.

  • CSS (Cancer Support Source)

    CSS is a distress screening tool for those who have been diagnosed with cancer, and for caregivers. This short questionnaire allows us to better recommend support programs and services for you. Please note you must also provide your date of birth above, which will be used as your login for the emailed survey.

  • Demographic Data

    As a non-profit organization that does not charge for our services, we rely on donations to underwrite our programs. The information given in this next section helps us secure funding and will be provided to funders only in terms of combined demographic data of all participants with no identifying information. You answers will not affect your ability to access all programs at CSCDE at no charge.

  • Cancer patients/survivors only

    Please complete the following, all others scroll to next page:

  • Participation Guidelines

    Please review and sign in the box provided

  • By my signature below I understand and agree:

    If I am not feeling well or have reason to suspect I have COVID or another contagious illness, I will not expose others and will participate virtually as appropriate. If appropriate, or if requested by the staff, I will wear a mask when in-person at CSCDE to protect myself and those around me.

    If I choose to participate in a support group, I will respect the confidentiality of what is shared in group. I understand that periodically interns may be part of the support group I attend and understand that all interns also respect participant’s confidentiality.

    If I participate in any Healthy Lifestyle classes (yoga, tai chi, walking group, etc.), it is my responsibility to ascertain that there is no medical reason to prevent my participation in this activity and to abide by any limitations that might be set by my medical providers. I agree to take full responsibility for not exceeding my personal limits in the practice of the exercise program and for any injury I might suffer during my participation in classes.

    Photos and/or video may sometimes be taken (never in a support group), and these photos/videos may be used in promotion of CSCDE, with care taken to use this media as anonymously as possible. I always have the option to opt out of any photos and can request my picture not be taken.

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  • Thank you for taking the time to answer these questions!

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